Sexual dysfunction in women with chronic obstructive lung disease.

OBJECTIVE: To determine the prevalence of sexual dysfunction in women with COPD and the factors related to its presence. METHODS: Cross-sectional observational study during 2021, including women with COPD diagnosed by spirometry through convenience sampling. Data on age, smoking status, spirometric data, comorbidities and medications used were collected. A sexual health questionnaire was administered. RESULTS: The study included 101 women with a mean age of 59.7 (11.3) years. All had experienced a change in sexual activity, with 44% attributing it to COPD. Among them, 51.5% experienced dyspnea during coitus. The prevalence of sexual dysfunction was 52.5%. Women with sexual dysfunction were older and had a lower Tiffeneau index. Furthermore, they consumed alcohol more frequently and had hypertension and cerebrovascular disease, and less often, they had diabetes and heart failure. However, they scored lower on the Charlson index corrected for age. Patients with sexual dysfunction used inhaled triple therapy less frequently. CONCLUSIONS: Sexual dysfunction is common in women with COPD. Further studies are needed to investigate its causes, mechanisms, and potential treatments.

Recommendations for the prevention of healthcare-associated infections in nursing homes.

Nursing homes (NH) conceptually should look as much like a home as possible. However NH have unquestionable similarities with a nosocomium as they are places where many patients with underlying diseases and comorbidities accumulate. There is evidence of transmission of microorganisms between residents and between residents and caregivers. We have not found any recommendations specifically aimed at the prevention of nosocomial infections in NH by the major Public Health Agencies and, therefore, the Health Sciences Foundation (Fundación de Ciencias de la Salud) has convened a series of experts and 14 Spanish scientific societies to discuss recommendations that could guide NH personnel in establishing written programs for the control and reduction of these infections. The present document is the result of these deliberations and contains suggestions for establishing such control programs on a voluntary and flexible basis in NH. We also hope that the document can help the health authorities to encourage this control activity in the different territorial areas of Spain. In our opinion, it is necessary to draw up a written plan and establish the figure of a coordinator or person responsible for implementing these projects. The document includes measures to be implemented and ways of quantifying the reality of different problems and of monitoring the impact of the measures established.

RECALMIN IV. Evolution in the activity of internal medicine units of the National Health System (2008-2021).

AIMS: This work aims to analyze the structure, activity, and outcomes of internal medicine units and departments (IMU) of the Spanish National Health System (SNHS) and to analyze the challenges for the specialty and propose policies for improvement. It also aims to compare the results from the 2021 RECALMIN survey with IMU surveys from previous years (2008, 2015, 2017, 2019). METHODS: This work is a cross-sectional, descriptive study of IMUs in acute care general hospitals of the SNHS that compares data from 2020 with previous studies. The study variables were collected through an ad hoc questionnaire. RESULTS: Between 2014 and 2020, hospital occupancy and discharges by IMU increased (annual mean of 4% and 3.8%, respectively), as did hospital cross-consultation and initial consultation rates (2.1% in both cases). E-consultations increased notably in 2020. Risk-adjusted mortality and length of hospital stay did not show significant changes from 2013-2020. Progress in the implementation of good practices and systematic care for complex chronic patients was limited. A consistent finding in RECALMIN surveys was the variability among IMUs in terms of resources and activity, though no statistically significant differences were found in regard to outcomes. CONCLUSIONS: There is considerable room for improvement in the operation of IMUs. The reduction in unjustified variability in clinical practice and inequities in health outcomes are a challenge for IMU managers and the Spanish Society of Internal Medicine.

Erectile dysfunction in patients with COPD. A systematic review and meta-analysis.

INTRODUCTION: Studies on sexuality in patients with chronic obstructive pulmonary disease (COPD) are scarce and have yielded conflicting results. Our aim was to determine the prevalence of erectile dysfunction (ED) and associated factors in patients with COPD. METHODS: Articles with data on ED prevalence in patients diagnosed with COPD through spirometry were searched for in the PubMed, Embase, Cochrane Library, and Virtual Health Library databases from the year of their creation until January 31, 2021. The prevalence of ED was assessed with a weighted mean of the studies. A meta-analysis was performed using the Peto fixed-effect model to evaluate the association of COPD with ED. RESULTS: Fifteen studies were ultimately included. The weighted prevalence of ED was 74.6%. A meta-analysis with four studies and 519 individuals showed an association of COPD with ED (estimated weighted odds ratio 2.89, 95% CI 1.93-4.32, p<0.001), with a non-negligible degree of heterogeneity (I2 57%). In the systematic review, age, smoking, degree of obstruction, oxygen saturation, and previous health status were associated with a higher prevalence of ED. CONCLUSIONS: ED is common in patients with COPD and its prevalence is higher than in the general population.

Prevalence and impact on prognosis of right-bundle branch block in patients with acute heart failure: Findings from the RICA registry.

OBJECTIVES: This work aims to determine the prevalence, characteristics, and impact on prognosis of right bundle branch block (RBBB) in a cohort of acute heart failure (AHF) patients. METHODS: We prospectively analyzed 3,638 AHF patients included in the RICA registry (National Heart Failure Registry of the Spanish Internal Medicine Society). We independently analyzed the relationship between baseline and clinical characteristics and the presence of RBBB as well as the potential impact of RBBB on 1-year all-cause mortality and a composite endpoint of 90-day post-discharge hospitalization or death. RESULTS: The prevalence of RBBB was 10.9%. Patients with RBBB were older, a higher proportion were male, had more pulmonary comorbidities, had higher left ventricular ejection fraction values, and had worse functional status. There were no differences in risk for patients with RBBB, with an adjusted hazard ratio (95% confidence interval) for 1-year mortality of 1.05 (0.83-1.32), and for the composite endpoint of 90-day post-discharge hospitalization or death of 0.97 (0.74-1.25). These results were consistent on the sensitivity analyses. CONCLUSIONS: Few patients with AHF present with RBBB, which is consistently associated with advanced age, male sex, pulmonary comorbidities, preserved left ventricular ejection fraction, and worse functional status. Nonetheless, after considering these factors, RBBB in AHF patients is not associated with worse outcomes.

Recommendations on the comprehensive, multidimensional assessment of hospitalized elderly people. Position of the Spanish Society of Internal Medicine.

This position paper describes the most relevant and essential aspects of a comprehensive, multidimensional assessment of hospitalized elderly people. The change in demographic patterns and the epidemiological profiles of diseases makes it necessary for internal medicine departments to adapt in order to take into account the vulnerabilities of the elderly in this context. A comprehensive, multidimensional assessment and the multidisciplinary development of a care plan during hospitalization can have an impact in terms of preventing mortality, disability, and institutionalization at discharge. It is necessary for all internists to acquire skills to improve the hospitalization experience in the elderly and obtain better health outcomes in our patients. This document has been developed by the Focus Group on Aging and the Polypathological and Advanced Age Working Group and endorsed by the Spanish Society of Internal Medicine.

Prognostic value of ambulatory blood pressure values in elderly patients with heart failure. Results of the DICUMAP study.

INTRODUCTION: Ambulatory blood pressure monitoring (ABPM) has demonstrated value in the prognostic assessment of hypertensive patients with heart failure (HF) with or without other cardiovascular diseases. The objective of this study was to evaluate whether ABPM can identify subjects with HF with a worse prognosis. METHODS AND RESULTS: Prospective multicenter study that included clinically stable outpatients with HF. All patients underwent ABPM. A total of 154 patients from 17 centers were included. Their mean age was 76.8 years (± 8.3) and 55.2% were female. In total, 23.7% had HF with a reduced ejection fraction (HFrEF), 68.2% were in NYHA functional class II, and 19.5% were in NYHA functional class III. At one year of follow up, there were 13 (8.4%) deaths, of which 10 were attributed to HF. Twenty-nine patients required hospitalization, of which 19 were due to HF. The presence of a non-dipper BP pattern was associated with an increased risk for readmission or death at one year of follow-up (25% vs. 5%; p=.024). According to a Cox regression analysis, more advanced NYHA functional class (hazard ratio 3.51; 95% CI 1.70-7.26; p=.001; for NYHA class III vs. II) and a higher proportional nocturnal reduction in diastolic BP (hazard ratio 0.961; 95%CI 0.926-0.997; p=.032 per 1% diastolic BP reduction) were independently associated with death or readmission at one year. CONCLUSION: In older patients with chronic HF, a non-dipper BP pattern measured by ABPM was associated with a higher risk of hospitalization and death due to HF.

Spanish and Portuguese Societies of Internal Medicine consensus guideline about best practice in end-of-life care.

AIM: To develop consensus recommendations about good clinical practice rules for caring end-of-life patients. METHODS: A steering committee of 12 Spanish and Portuguese experts proposed 37 recommendations. A two rounds Delphi method was performed, with participation of 105 panelists including internists, other clinicians, nurses, patients, lawyers, bioethicians, health managers, politicians and journalists. We sent a questionnaire with 5 Likert-type answers for each recommendation. Strong consensus was defined when >95% answers were completely agree or >90% were agree or completely agree; and weak consensus when >90% answers were completely agree or >80% were agree or completely agree. RESULTS: The panel addressed 7 specific areas for 37 recommendations spanning: identification of patients; knowledge of the disease, values and preferences of the patient; information; patient's needs; support and care; palliative sedation, and after death care. CONCLUSIONS: The panel formulated and provided the rationale for recommendations on good clinical practice rules for caring end-of-life patients.

Recommendations on the comprehensive, multidimensional assessment of hospitalized elderly people. Position of the Spanish Society of Internal Medicine. / Recomendaciones sobre la valoración integral y multidimensional del anciano hospitalizado. Posicionamiento de la Sociedad Española de Medicina Interna.

This position paper describes the most relevant and essential aspects of a comprehensive, multidimensional assessment of hospitalized elderly people. The change in demographic patterns and the epidemiological profiles of diseases makes it necessary for internal medicine departments to adapt in order to take into account the vulnerabilities of the elderly in this context. A comprehensive, multidimensional assessment and the multidisciplinary development of a care plan during hospitalization can have an impact in terms of preventing mortality, disability, and institutionalization at discharge. It is necessary for all internists to acquire skills to improve the hospitalization experience in the elderly and obtain better health outcomes in our patients. This document has been developed by the Focus Group on Aging and the Polypathological and Advanced Age Working Group and endorsed by the Spanish Society of Internal Medicine.

The Hospital of the Future in 10 points. / El hospital del futuro en 10 puntos.

Over the course of 2018 and 2019, the Spanish Society of Internal Medicine carried out a project called "The Future Hospital." Based on cumulative knowledge on the Spanish National Health System, this project seeks to transfer the observations on the organization of healthcare in future hospitals made by the Royal College of Physicians in the United Kingdom to the context of the Spanish healthcare system. The project's participants included numerous scientific and medical societies, professional associations in the health sector, and patient associations. This aim of this article is to highlight, in 10 points, predictions that arose from this project that we consider to be the most relevant, reserving the last point for the challenges for the field of internal medicine that can be surmised from these proposals.

Spanish and Portuguese Societies of Internal Medicine consensus guideline about best practice in end-of-life care. / Guía de práctica clínica de consenso sobre buenas prácticas en los cuidados al final de la vida de las Sociedades Española y Portuguesa de Medicina Interna.

AIM: To develop consensus recommendations about good clinical practice rules for caring end-of-life patients. METHODS: A steering committee of 12 Spanish and Portuguese experts proposed 37 recommendations. A two rounds Delphi method was performed, with participation of 105 panelists including internists, other clinicians, nurses, patients, lawyers, bioethicians, health managers, politicians and journalists. We sent a questionnaire with 5 Likert-type answers for each recommendation. Strong consensus was defined when > 95% answers were completely agree or > 90% were agree or completely agree; and weak consensus when > 90% answers were completely agree or > 80% were agree or completely agree. RESULTS: The panel addressed 7 specific areas for 37 recommendations spanning: identification of patients; knowledge of the disease, values and preferences of the patient; information; patient's needs; support and care; palliative sedation, and after death care. CONCLUSIONS: The panel formulated and provided the rationale for recommendations on good clinical practice rules for caring end-of-life patients.

Sarcopenia, frailty, cognitive impairment and mortality in elderly patients with non-valvular atrial fibrillation. / Sarcopenia, fragilidad, deterioro cognitivo y mortalidad en pacientes ancianos con fibrilación auricular no valvular.

OBJECTIVES: To determine the prevalence of sarcopenia, frailty and cognitive impairment in elderly patients with nonvalvular atrial fibrillation (NVAF) and the factors' influence on survival. METHODS: Prospective, multicentre cohort study of patients older than 75 years with NVAF hospitalised in internal medicine departments in Spain. For each patient, we recorded the creatinine, haemoglobin and platelet levels, the scores on the CHA2DS2-VASc and HAS-BLED scales and Charlson index, as well as the use of oral anticoagulants. We measured sarcopenia with the SARC-F scale, frailty with the FRAIL scale and cognitive impairment with the Short Portable Mental State Questionnaire. We also conducted a 1-year follow-up. RESULTS: The study included 596 patients with NVAF, with a mean age of 84.9 (SD: 5.2) years. Of these, 295 (49.5%) presented sarcopenia, 305 (51.2%) presented frailty, and 251 (42.1%) presented cognitive impairment. At the end of 1year, 226 (37.9%) patients had died. Mortality was greater for the patients with sarcopenia, frailty and cognitive impairment. In the multivariate analysis, sarcopenia (HR: 1.775; 95%CI: 1.270-2.481), age, comorbidity and a history of peripheral embolism were associated with increased mortality, and the use of oral anticoagulants at discharge (HR: 0.415; 95%CI: 0.307-0.560) was associated with lower mortality. CONCLUSIONS: Sarcopenia, frailty and cognitive impairment are very common in elderly patients with NVAF and are frequently associated. Sarcopenia was associated with increased mortality.

Simplification of the Barthel scale for screening for frailty and severe dependency in polypathological patients. / Simplificación de la escala de Barthel para el cribado de fragilidad y dependencia severa en pacientes pluripatológicos.

OBJECTIVES: To analyse the sensitivity, specificity and positive predictive (PPV) and negative predictive (NPV) values of each measure of the Barthel index (BI) compared with the full questionnaire for polypathological patients (PPPs). METHODS: Multicentre cross-sectional study. We considered 2 cut-off points for the BI (≥90 points for screening frailty and <60 points for diagnosing severe dependence). For each measure and combination of 2 measures, we calculated the sensitivity, specificity, PPV and NPV with respect to the full BI. RESULTS: The mean BI of the 1,632 included PPPs (mean age, 77.9±9.8years; 53% men) was 69±31 (<90 for 58.7% and <60 for 31.4% of the patients). The "feeding" measure achieved the highest NPV, for a BI ≥60 and ≥90 points (87% and 99.6%, respectively). The "walking" and "going up and down stairs" measures achieved the highest PPV, for a BI ≥60 and ≥90 (99.2%/99.5% and 81%/92%, respectively. The combination of the 2 measures increased the PPV to 95% and 99.6%, respectively. CONCLUSIONS: PPPs in hospital settings have a high rate of functional impairment. The measure for feeding achieved the highest NPV and can therefore be employed for diagnosing severe dependence. The combination of the measures for walking and going up and down stairs achieved the highest PPV and can therefore be employed to propose frailty screening for PPPs.

Consensus for managing patients with chronic obstructive pulmonary disease according to the CODEX index. / Consenso para el manejo de pacientes con EPOC según el índice CODEX.

The comorbidity, obstruction, dyspnoea, exacerbations (CODEX) index is the first multicomponent scale designed to predict the risk of readmissions and mortality at 1 year for patients hospitalised for chronic obstructive pulmonary disease (COPD). The index includes the comorbidities (C) (measured by the Charlson index), the degree of obstruction (O) (assessed by the forced expiratory volume in 1 second percentage), dyspnoea (D) (stratified according to the modified Medical Research Council scale) and exacerbations (EX) in the previous year. Our objective was to prepare recommendations based on the index's various components for personalised therapeutic management. To this end, we performed a literature search based on guidelines, consensuses and systematic reviews, as a basis for preparing recommendations on basic concepts, comorbidities, dyspnoea, pulmonary obstruction, exacerbations and follow-up. The recommendations were then subjected to an external assessment process by a multidisciplinary group of 62 experts. In total, 108 recommendations were created, 96 of which achieved consensus, including the recommendation that COPD be considered a high-risk cardiovascular disease, as well as several specific recommendations on managing the various comorbidities. A consensus was reached on the recommended treatments in the guidelines for the various levels of obstruction, dyspnoea and exacerbations, adapted to the CODEX scores. Advice is also offered for patient follow-up after hospital discharge, which includes aspects on assessment, treatment and care coordination.

RECALMIN. Four years of growth of the internal medicine units of the Spanish National Health System (2013-2016). / RECALMIN. Cuatro años de evolución de las Unidades de Medicina Interna del Sistema Nacional de Salud (2013-2016).

OBJECTIVES: To compare the structure, resources and activity of the internal medicine units (IMUs) of the Spanish National Health System (SNHS) in 2013 and 2016. To analyse the differences between IMUs in 2016 by hospital size. MATERIAL AND METHODS: We conducted a comparison of 2 descriptive cross-sectional studies of IMUs in general acute care hospitals of the Spanish National Health System, with data referring to 2013 and 2016. The variables were collected via an ad hoc questionnaire (RECALMIN survey). RESULTS: Between 2013 and 2016, the demand for care increased dramatically (with an annual average of 11% in hospital discharges and 16% in first consultations), and comorbidity slightly increased (2%). During this period, the mean productivity of IMUs increased 16.7% (0.6±0.3 vs. 0.7±0.3; P=.09), and the mean stay decreased 10% (9±2.2 vs. 8.1±2.1 days; P=.001). Progress in implementing good practices and systematic care for complex chronic patients was scarce. Both surveys found variability among IMUs and marked differences among IMUs of hospitals of different sizes. CONCLUSIONS: IMUs responded to the increased burden of care they supported during 2013-2016 by improving their efficiency and productivity; however, advances in implementing good practices, including care for chronic complex patients, were scare. The significant variability in the indicators of structure, activity and management models found in 2013 remained in 2016.

End-of-life care for patients hospitalised in internal medicine departments. / Cuidados en los últimos días de vida en los pacientes hospitalizados en medicina interna.

OBJECTIVES: To describe the care provided at the end of life for patients who die in internal medicine departments. METHODS: An observational, cross-sectional, retrospective multicentre, clinical audit study was conducted where each hospital included the first 10 patients who died in the internal medicine department starting on December 1, 2015. We collected demographic and clinical data and information regarding the circumstances and care at the time of death. RESULTS: The study included 1,447 patients with a median age of 84 years. Of these, 1,065 (74.3%) were polypathological, 751 (51.9%) were terminal and 248 (17.1%) had cancer. For the terminal patients, do-not-resuscitate orders were established for 539 (73.3%), and palliative sedation was performed for 422 (57.4%). There was no record as to whether psychological, religious or grief care was provided in 32%, 64.8% and 44.1% of the terminal patients, respectively. The patients with cancer were more often competent to make decisions (54.4% vs. 15.5%; P<.001), knew their prognosis (42.6% vs. 8.6%; P<.001), received psychological care (24.9% vs. 8.6%; P<.001), died in an individual room (64.6% vs. 44.4%; P<.001) and were accompanied (81.9% vs. 71.9%; P=.003). Their relatives also more frequently received grief care (15.6% vs. 8.2%; P=.002). CONCLUSIONS: There is insufficient recording in the medical history as to the end-of-life care. There are differences in the care provided to patients with cancer and to those without cancer.